Adult Education Program

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Adult Education Program
FY2018 Intake Assessment Form
Completion of this form is required for all adult learners in all programs. Required data is in bold with an asterisk (*).
Please print legibly. All signatures should be in ink.
*Pre-test date, form/level, score:
*Entry Educational Functioning Level:
Site/Class:
Other Information:
Hard copies of all assessment records must be maintained in the student permanent record.
STUDENT DATA
Today’s Date: ________________________
Orientation Date: __________________________
Social Security Number: ________ - ______ - ________ *Date of Birth: _______/_______/_______ Age: _________
Month / Day / Year
*Name: _________________________________________________________________________________________
Last
First
Middle/Former Name
Suffix
*Hispanic/
No, not Hispanic/Latino
*Gender:
Male
Latino:
Yes, Hispanic/Latino
Female
*Race:
American Indian or Alaska Native
FOR PROGRAM USE ONLY:
Asian
(Select one or more)
Institution 1: ___________________________
Black or African-American
Native Hawaiian or Other Pacific Islander
Institution 2: ___________________________
White
*Highest School Grade Completed: (select one)
st
th
th
th
No School Grade
1
grade
4
grade
7
grade
10
grade
Completed
nd
th
th
th
2
grade
5
grade
8
grade
11
grade
rd
th
th
th
3
grade
6
grade
9
grade
12
grade
*Highest Educational Certificate/Diploma/Degree Completed: (select one)
Bachelor’s degree
None
Certificate of Attendance/Completion
Master’s degree
One or more years of Postsecondary Education
Specialist’s degree
Postsecondary Technical or Vocational Certificate
High School Diploma
Associate’s degree
Doctorate or Professional degree
High School Equivalency (GED)
*Where was your highest level of education completed?
U.S.-Based Schooling
Non-U.S.-Based Schooling
How did you hear about the program?
Print Media
Friend
TV
Radio
Referral
Internet
Family
Previous Enrollment
Previous Enrollment in another program: If so, which one? ___________________________
If you were referred, select the referring agency:
Division of Family and Children’s Services/TANF/SNAP
Georgia Department of Corrections
Georgia Vocational Rehabilitation Agency
Georgia Department of Labor
Local Workforce Development Board/Area
Georgia Department of Transportation
Other _______________________________________
*Special Enrollment (if applicable):
*Correctional/Institutionalized Programs (if applicable):
Ability to Benefit
Currently Incarcerated in a Correctional Institution
Dual Enrollment
Currently Participating in a Community Corrections program
ACCUPLACER Test Review
Currently on Probation Supervision
Banner ID __________________
Currently on Parole Supervision
Other ______________________
Currently attending a recovery/rehabilitation program
Technical College System of Georgia, Office of Adult Education, Intake Assessment Form, Effective: July 1, 2017
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